| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The home's self-assessment, completed on 11/25/24, was not conducted either within 3-6 months of the current license's expiration date of 2/22/2025 or within 6-9 months following the last annual inspection by the Department completed 12/20/23. [Repeated Violation-12/19/23, et al] | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| A compliance calendar has been implemented to ensure timely completion of the annual self-assessment. Management was trained regarding the requirements for completing and documenting the annual self-assessment. |
02/27/2025
| Implemented |
| 6400.16 | The agency neglected Individual #1 for failure to protect from hazards in the following manner: At 10:28 AM on 12/6/24, the home's indoor thermostat read 46 degrees Fahrenheit. Individual #1 and Direct Support Professional #2, were observed wearing coats and heavy clothing during the inspection. Operations Manager/ Accountant #1 stated that staff should know when to report maintenance issues with the boiler system before it gets this cold. Operations Manager/ Accountant #1, then, called a heating & cooling company to fix the boiler system. In addition, the boiler system not working also left the individual without hot running water. Hot water temperatures on 12/6/24 in the home did not exceed 51.4 degrees Fahrenheit. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | The furnace was repaired on 12/6/24. The incident was reported on 12/7/24 as required by regulation. All staff received a refresher training regarding the facility's policies on abuse, neglect, and exploitation, with an emphasis on recognizing and preventing neglect. A quality assurance process has been implemented, including random, unannounced observations by a site inspector and management to ensure compliance with rights and supervision policies. |
02/27/2025
| Implemented |
| 6400.43(b)(1) | Program Director/ Chief Executive Officer Designee #3 did not ensure that staff were properly trained on the following policies to ensure implementation: a) Freedom Now Home Care's "Emergency Evacuation Procedure" states, "In the event of an emergency, staff will assist in evacuating the individual(s) out of the residence, contact the Manager immediately, and then contact the American Red Cross who will provide temporary emergency shelter for the immediate area. On 12/6/24, Individual #1 was not relocated to a temporary emergency shelter from their residence that lacked a functioning boiler system, therefore, subjecting Individual #1 to a home with an indoor temperature below 65 degrees Fahrenheit and without running hot water. b) Freedom Now Home Care's "Unusual Incident Policy and Procedures" states, "all staff must remain vigilant and report any unusual incidents immediately to their supervisor or the designated Incident Coordinator," and that "staff must complete an 'Unusual Incident Report Form' within 24 hours of the incident and submit the form to the Incident Coordinator for review and further action;" c) On 12/6/24, staff had not reported maintenance issues to their supervisor(s), as Individual #1 was residing in a home without adequate heat and a functioning boiler system. Individual #1 was wearing a heavy coat to keep warm. Additionally, Operations Manager/ Accountant #1 stated that staff should know when to report maintenance issues with the boiler system before it gets this cold. Operations Manager/ Accountant #1, then, called a Heating & Cooling company to address the heating system; and d) At 1:28 PM on 12/6/24, the Department informed Program Director/ Chief Executive Officer Designee #3 via email to file an incident of neglect for Individual #1 into the Enterprise Incident Management System. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | The CEO/Director conducted a full review of administrative and management practices to identify gaps and ensure compliance with regulatory responsibilities. The CEO/Director retrained staff on safety and rights policies. A formal management oversight plan was implemented to ensure regular monitoring of all administrative and operational functions. The Management team completed additional training regarding their responsibilities under Chapter 6400.43(b)(1). |
02/27/2025
| Implemented |
| 6400.43(b)(3) | Program Director/ Chief Executive Officer Designee #3 did not ensure the health and safety of Individual #1 in the following manner: a) Staff were not properly trained to implement the agency's "Emergency Evacuation Procedure" and its "Unusual Incident Policy and Procedures." b) On 12/6/24, Individual #1 was not relocated to a temporary emergency shelter from their residence that lacked a functioning boiler system, therefore, subjecting Individual #1 to a home with an indoor temperature below 65 degrees Fahrenheit and without running hot water.; c) On 12/6/24, staff had not reported maintenance issues to their supervisor(s), as Individual #1 was residing in a home without adequate heat and a functioning boiler system. Individual #1 was wearing a heavy coat to keep warm; and d) At 1:28 PM on 12/6/24, The Department informed Program Director/ Chief Executive Officer Designee #3 via email to file an incident of neglect for Individual #1 into the Enterprise Incident Management System. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | A safety plan was developed to ensure safety of individuals is maintained at all times with contingency plans for unexpected incidents. The Management team completed training on emergency and backup planning. |
02/25/2025
| Implemented |
| 6400.62(a) | Individual #1's Individual Support Plan, last updated on 11/4/24, states "[Individual #1] has not learned safety skills or cleaning using detergents and chemicals." At 10:58 AM on 12/6/24, the following items were unlocked underneath the kitchen sink: a 100-fluid ounce bottle of Pine Sol Cleaner and a 180-fluid ounce bottle of Clorox Cleaner+ Bleach. Laying on the dining room table where Individual #1 was eating, was an open 60-count box of Bounce dryer sheets. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Staff was retrained on proper poison storage. |
02/27/2025
| Implemented |
| 6400.64(a) | At 10:20 AM on 12/6/24, the following items were found on the basement floor near the laundry facility: two empty 250-fluid ounce All laundry detergent containers; seven used dryer sheets; an empty one-pound tub of Tide Pods; an empty 4.55-liter container of Gain laundry detergent; and a pair of loose socks. On top of the dryer there were two crumpled up thick layers of dryer lint surrounded by dust and particles. [Repeated Violation-1/19/23 et al and 12/19/23, et al] | Clean and sanitary conditions shall be maintained in the home. | Staff were retrained on sanitation policies. |
02/27/2025
| Not Implemented |
| 6400.64(d) | At 10:17 AM on 12/6/24, located in the kitchen was an open paper bag from Target with two light bulbs and an empty bag of chips inside of it. | Trash in the bathroom, dining and kitchen areas shall be kept in cleanable receptacles that prevent the penetration of insects and rodents. | Staff were retrained on sanitation policies. |
02/27/2025
| Implemented |
| 6400.64(f) | At 10:16 AM on 12/6/24, the trash receptacle located in the backyard was open with three white garbage bags protruding from its top, preventing its lid from closing. Five more white garbage bags were laying in the yard beside the open trash receptacle along with an empty Eggo Waffles box. [Repeated Violation-1/19/23 et al and 12/19/23, et al] | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Staff was retrained on sanitation procedures. |
02/27/2025
| Not Implemented |
| 6400.68(a) | On 12/6/24, the home lacked hot running water under pressure. At 10:32 AM, the hot water temperature at the tub in the home's only bathroom located on the upper level measured 50.9 degrees Fahrenheit. At 10:33 AM, the hot water temperature at the kitchen sink located on the home's main level measured 51.4 degrees Fahrenheit. | A home shall have hot and cold running water under pressure. | Management contacted the contracted HVAC provider on 12/6/2025 in order to repair the furnace. Management was retrained on back up/relocation procedures for unexpected incidents. |
02/27/2025
| Implemented |
| 6400.69(a) | At 10:28 AM on 12/6/24, the home's indoor thermostat read 46 degrees Fahrenheit. | The indoor temperature may not be less than 65°F during nonsleeping hours while individuals are present in the home. | Management contacted the contracted HVAC provider on 12/6/2025 in order to repair the furnace. Management was retrained on back up/relocation procedures for unexpected incidents. |
02/27/2025
| Implemented |
| 6400.70 | At 10:25 AM on 12/6/24, the only accessible telephone in the living room on the home's main level did not have a dial tone or access to an outside line. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| Management assessed the phone for possible repair and replaced it. |
02/27/2025
| Implemented |
| 6400.72(a) | At 10:24 AM on 12/6/24, the window facing side of the home in the living room was missing a screen. At 10:24 AM, the only window in the staff office located on the home's upper level did not have a screen. [Repeated Violation-1/19/23 et al and 12/19/23, et al] | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Management replaced the screen. |
02/27/2025
| Not Implemented |
| 6400.72(b) | At 10:22 AM on 12/6/24, a door to a storage room underneath the porch in the basement was leaning leftward off its frame with its middle and lower hinges detached. [Repeated Violation-1/19/23 et al and 12/19/23, et al] | Screens, windows and doors shall be in good repair. | Management contacted the contracted maintenance provider to replace the storage door. Management was retrained on identifying maintenance issues in the residential homes. |
02/27/2025
| Not Implemented |
| 6400.80(b) | At 10:17 AM on 12/6/24, a free-standing refrigerator and freezer unit was found in the backyard just beyond the steps leading from the kitchen exterior door. Inside the refrigerator were the following: a bottle of Kraft Classic Catalina dressing; a Pearl Milling bottle of maple syrup; a squeezable plastic jar of Grape jelly; and a 60-count box of Great Value Grade A eggs. Additionally, scattered throughout the interior of the refrigerator including its door were several black spots appearing to be a combination of dirt, mold, and/ or mildew. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Management contacted a removal service to discard of the bulk item. Staff was retrained on proper sanitation procedures as well as notification of hazards. |
02/27/2025
| Not Implemented |
| 6400.104 | The local fire department notification letter dated 4/19/24 for this home indicates that Individual #1 requires physical assistance to evacuate in the event of an actual fire, but it does not include a description or diagram of the exact location of their bedroom. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Management sent a formal written notification to the local fire department, including the home's address and a detailed floor plan indicating the exact locations of bedrooms for the individual requiring evacuation assistance. Staff were trained on the importance of maintaining current evacuation information and the proceedure for updating the fire department. |
02/27/2025
| Implemented |
| 6400.111(f) | On 12/6/24 fire extinguisher located in the home's accessible attic was last inspected and approved by a fire safety expert in April 2023. [Repeated Violation-12/19/23, et al] | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | Management contacted their contracted fire safety expert to inspect the attic's extinguisher and replace it. |
02/27/2025
| Implemented |
| 6400.112(g) | According to the written fire drill record submitted from 1/1/24 to 11/1/24, all drills were conducted on the first day of every month. | Fire drills shall be held on different days of the week and at different times of the day and night. | Management was retrained on proper fire safety documentation and procedures. |
02/27/2025
| Implemented |
| 6400.151(a) | Direct Support Professional #2's date-of-hire is 12/1/22. Direct Support Professional #2's last physical examination was completed on 9/6/22. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Management requested a copy of DSP #3's current physical and placed it in their file |
02/27/2025
| Not Implemented |
| 6400.214(b) | At 11:00 AM on 12/6/24, the following copies of Individual #1's current records at the home were missing: an assessment; an Individual Support Plan; a behavior support plan; an applicable psychological evaluation; a physical examination; a vision screening or examination; a hearing screening or examination; a dental examination; and a dental hygiene plan, as Individual #1's Individual Support Plan, last updated on 11/4/24, indicates they require verbal prompting to complete oral hygiene. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Management located the individual's residential binder and placed it in the home. |
02/27/2025
| Not Implemented |
| 6400.18(a)(5) | Enterprise Incident Management #:9517979 involving neglect for failure to provide needed supervision was discovered on 11/11/24 at 10:00 AM and reported on 11/15/24 at 12:03 PM. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Neglect.
| Management was retrained on incident management. |
02/27/2025
| Implemented |
| 6400.18(g) | Enterprise Incident Management #:9517979 involving neglect for failure to provide needed supervision was discovered on 11/11/24 at 10:00 AM. The field for the "Certified Investigator Date and Time," in the Department's Enterprise Management System was left blank. The incident was reported on 11/15/24 at 12:03 PM. Therefore, the agency did not assign a certified investigator within 24 hours of discovery. | The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person. | Management was retrained on incident management. |
02/27/2025
| Implemented |
| 6400.46(b) | Direct Support Professional #2 did not complete annual fire safety training in 2023 and 2024. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Management was retrained on the proper documentation of training records. |
02/27/2025
| Implemented |
| 6400.52(c)(1) | Direct Support Professional #2 completed annual training for the 2023 calendar year, which included training in the application of person-centered practices, community integration, client choice, and supporting clients to develop and maintain relationships. This training was completed by "self-reading" the material. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Management reviewed and revised current agency training to ensure it encompassed The Application of Person-Centered Practices, Community Integration, Individual Choice and Supporting Individuals To Develop and Maintain Relationships. A training schedule was developed to ensure all employees complete their required training hours within the calendar year. Management was trained on the importance of monitoring and documenting staff hours. |
02/27/2025
| Not Implemented |
| 6400.52(c)(2) | Direct Support Professional #2 did not complete annual training for the 2023 calendar year that included the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Management reviewed and revised current agency training to ensure it encompassed The Prevention, Decection and Reporting of Abuse, Suspected Abuse and Alleged Abuse. A training schedule was developed to ensure all employees complete their required training hours within the calendar year. Management was trained on the importance of monitoring and documenting staff hours. |
02/27/2025
| Not Implemented |
| 6400.52(c)(3) | Direct Support Professional #2 did not complete annual training for the 2023 calendar year that included content on individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Management reviewed and revised current agency training to ensure it encompassed Individual Rights. A training schedule was developed to ensure all employees complete their required training hours within the calendar year. Management was trained on the importance of monitoring and documenting staff hours. |
02/27/2025
| Not Implemented |
| 6400.52(c)(4) | Direct Support Professional #2 did not complete annual training for the 2023 calendar year that included recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Management reviewed and revised current agency training to ensure it encompassed Recognizing and Reporting Incidents. A training schedule was developed to ensure all employees complete their required training hours within the calendar year. Management was trained on the importance of monitoring and documenting staff hours. |
02/27/2025
| Not Implemented |
| 6400.52(c)(5) | Direct Support Professional #2 did not complete annual training for the 2023 calendar year that included individual-specific reviews of the safe and appropriate use of behavior supports. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Management reviewed and revised current agency training to ensure it encompassed The Safe and Appropriate Use of Behavior Supports. A training schedule was developed to ensure all employees complete their required training hours within the calendar year. Management was trained on the importance of monitoring and documenting staff hours. |
02/27/2025
| Not Implemented |
| 6400.52(c)(6) | Direct Support Professional #2 did not complete annual training for the 2023 calendar year that included individual-specific reviews of the implementation of the individual support plan. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Management reviewed and revised current agency training to ensure it encompassed Implementation of the Individual Plan. A training schedule was developed to ensure all employees complete their required training hours within the calendar year. Management was trained on the importance of monitoring and documenting staff hours. |
02/27/2025
| Not Implemented |